Occurrence, Phenotypic and Molecular Characteristics of Extended-Spectrum Beta-Lactamase-Producing Escherichia coli in Healthy Turkeys in Northern Egypt

Poultry is one of the most important reservoirs for zoonotic multidrug-resistant pathogens. The indiscriminate use of antimicrobials in poultry production is a leading factor for development and dissemination of antimicrobial resistance. This study aimed to describe the prevalence and antimicrobial resistance of E. coli isolated from healthy turkey flocks of different ages in Nile delta region, Egypt. In the current investigation, 250 cloacal swabs were collected from 12 turkey farms in five governorates in the northern Egypt. Collected samples were cultivated on BrillianceTM ESBL agar media supplemented with cefotaxime (100 mg/L). The E. coli isolates were identified using MALDI-TOF-MS and confirmed by a conventional PCR assay targeting 16S rRNA-DNA. The phenotypic antibiogram against 14 antimicrobial agents was determined using the broth micro-dilution method. DNA-microarray-based assay was applied for genotyping and determination of both, virulence and resistance-associated gene markers. Multiplex real-time PCR was additionally applied for all isolates for detection of the actual most relevant Carbapenemase genes. The phenotypic identification of colistin resistance was carried out using E-test. A total of 26 E. coli isolates were recovered from the cloacal samples. All isolates were defined as multidrug-resistant. Interestingly, two different E. coli strains were isolated from one sample. Both strains had different phenotypic and genotypic profiles. All isolates were phenotypically susceptible to imipenem, while resistant to penicillin, rifampicin, streptomycin, and erythromycin. None of the examined carbapenem resistance genes was detected among isolates. At least one beta-lactamase gene was identified in most of isolates, where blaTEM was the most commonly identified determinant (80.8%), in addition to blaCTX-M9 (23.1%), blaSHV (19.2%) and blaOXA-10 (15.4%). Genes associated with chloramphenicol resistance were floR (65.4%) and cmlA1 (46.2%). Tetracycline- and quinolone-resistance-associated genes tetA and qnrS were detected in (57.7%) and (50.0%) of isolates, respectively. The aminoglycoside resistance associated genes aadA1 (65.4%), aadA2 (53.8%), aphA (50.0%), strA (69.2%), and strB (65.4%), were detected among isolates. Macrolide resistance associated genes mph and mrx were also detected in (53.8%) and (34.6%). Moreover, colistin resistance associated gene mcr-9 was identified in one isolate (3.8%). The class 1 integron integrase intI1 (84.6%), transposase for the transposon tnpISEcp1 (34.6%) and OqxB -integral membrane and component of RND-type multidrug efflux pump oqxB (7.7%) were identified among the isolates. The existing high incidence of ESBL/colistin-producing E. coli identified in healthy turkeys is a major concern that demands prompt control; otherwise, such strains and their resistance determinants could be transmitted to other bacteria and, eventually, to people via the food chain

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Laparoscopic Management of Malfunctioning Peritoneal Dialysis Catheters

Objectives: Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. Malfunction of the peritoneal catheter is a frequent complication in peritoneal dialysis (PD). Laparoscopy is a minimal invasive technique that allows rescue therapy of malfunctioning catheters and consecutive immediate resumption of PD. The purpose of this study is to present our experiences with laparoscopic repair of peritoneal catheter dysfunctionMethods: Between April 2006 and March 2010, 21 cases of laparoscopic interventions were performed for the salvage of malfunctioning CAPD catheter. Two trocars (5 mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed and complications.Results: The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in fifteen cases, malpositioning in four cases, and tunnel infection in the remaining two cases. Adhesiolysis was performed in cases with adhesions. In the cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn and exchanged because of infection. There were no mechanical or infection problems. The overall success rate of catheter function (>30 days after laparoscopy) was 100%, except for two cases in which the catheters had to be removed.Conclusion: Laparoscopy is a safe, highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction

Acute Biliary Pancreatitis: Diagnosis and Treatment

Gallstones are the commonest cause of acute pancreatitis (AP), a potentially life-threatening condition, worldwide. The pathogenesis of acute pancreatitis has not been fully understood. Laboratory and radiological investigations are critical for diagnosis as well prognosis prediction. Scoring systems based on radiological findings and serologic inflammatory markers have been proposed as better predictors of disease severity. Early endoscopic retrograde cholangiopancreatography (ERCP) is beneficial in a group of patients with gallstone pancreatitis. Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for acute biliary pancreatitis. The timing of cholecystectomy, following ERCP, for biliary pancreatitis can vary markedly depending on the severity of pancreatiti

Outcome of Early versus Delayed Evacuation of Spontaneous Lobar Hematomas in Unconscious Adults

Objective: To explore the difference in outcomes of medium-sized lobar hematomas evacuated in early versus delayed fashion among unconscious noncomatose individuals. Methods: A retrospective analysis of demographic, clinical, and radiological data of unconscious patients admitted with lobar hematomas during 18 years was performed. Time to surgery was compared in various patient variables and characteristics. Outcome groups (favorable and poor) were also compared to find out any association with surgery timing, as well as potential indicators of outcome and mortality. Results: The mean follow-up period in this study was 7.5 months after discharge. Two-thirds of the patients carried favorable prognosis at final follow-up with mortality (7.3%) included among poor cases. Time to surgery was not associated to any of the patient characteristics, except for international normalized ratio and associated chest problems which represented the main indicators of delayed surgery. Rebleeding after evacuation was associated with shorter time to surgery in clots ≤35 cc but not in the whole group. Poor outcome was significantly associated with higher basal glucose levels, bigger hematomas, rebleeding after surgery, and delayed evacuation of clots ≤35 cc. The presence of mild intraventricular hemorrhage (IVH) per se was not associated with increased mortality or poor outcome; however, its volume was. Conclusion: Smaller lobar hematomas (≤35 cc) in unconscious adults (Glasgow Coma Scale 8–13) may be managed with initial conservative treatment, while larger hematomas (≤35 cc) are better evacuated as early as possible. Basal glucose levels and volume of mild IVH should be considered in the future management planes

Substernal Thyroid Masses

A thyroid mass, most often a non toxic colloid goiter or occasionally an adenoma, is not an unusual finding below the level of the thoracic inlet.1 In 1992 Creswell and Wells estimated that these tumors comprise 5.8% of all mediastinal lesions.1 There is no standard definition for thyroid glands extending below the thoracic inlet, but such masses descend from their original cervical location for more than 2 or 3 cm below the thoracic inlet, and are not truly primary tumors of the mediastinum. They preserve the connection between the thoracic and cervical portion and receive their blood supply from the neck.2,3 In 1940, the seminal report of Wakeley and Mulvany divided intrathoracic thyroid masses into 3 types; (1)”Small substernal extension” of a mainly cervical mass, (2) “Partial” intrathoracic, in which the major portion of the mass is situated within the thorax, and (3)”Complete” in which all of the mass lies within the thoracic cavity

Adhesive small bowel obstruction due to pelvic inflammatory disease: A case report

We report a rare case of a 32-year-old woman with adhesive small bowel obstruction due to pelvic inflammatory disease. She had no history of abdominal surgery, gynecological complaints or constitutional symptoms of chronic illness. The diagnosis was based on the laparoscopic findings of small bowel adhesions, free peritoneal fluid, “violin string” adhesions of Fitz-Hugh–Curtis syndrome and left hydrosalpinx. Laparoscopic adhesiolysis was performed successfully, and the patient had an uneventful postoperative course. The authors conclude that pelvic inflammatory disease should be included as a cause of adhesive small bowel obstruction in sexually active young women with no history of abdominal surgery or constitutional symptoms of chronic disease. When performed by experienced surgeons, laparoscopy in such patients is feasible and safe